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Certificat de Residence Fiscale FR
Certificat de Residence Fiscale FR
CERTIFICATE OF RESIDENCE
12816*01
I) Types of income
Dividends
Normal procedure
Interest
Simplified procedure
Royalties
II) Beneficiary
Surname and first name, or
company name
....................................................................................................................................................
Occupation
....................................................................................................................................................
....................................................................................................................................................
or registered office
....................................................................................................................................................
............................................................................................................................................
....................................................................................................................................................
- For the purposes of the abovementioned tax treaty, the beneficiary is a resident of (or in the case of pension fund or
an investment company , is established in) .... ;
- The beneficiary of the income is subject to taxation by the authority under the tax identification number ...
(where applicable).
...
Date and place
@ internet - DGFiP
...........................................................................................................................................................................
Address
...........................................................................................................................................................................
...........................................................................................................................................................................
SIREN number
...........................................................................................................................................................................
...
Date and place
Seal
...........................................................................................................................................................................
Address
...........................................................................................................................................................................
...........................................................................................................................................................................
The abovenamed institution hereby certifies that, to the best of its knowledge, the applicant is a resident of the United States and
that the information provided on this form is correct.
...
Date and place
Seal
: .............. %
@ internet - DGFiP
5000-EN
To be kept by
the beneficiary
CERTIFICATE OF RESIDENCE
12816*01
I) Types of income
Dividends
Normal procedure
Interest
Simplified procedure
Royalties
II) Beneficiary
Surname and first name, or
company name
....................................................................................................................................................
Occupation
....................................................................................................................................................
....................................................................................................................................................
or registered office
....................................................................................................................................................
............................................................................................................................................
....................................................................................................................................................
- For the purposes of the abovementioned tax treaty, the beneficiary is a resident of (or in the case of pension fund or
an investment company , is established in) .... ;
- The beneficiary of the income is subject to taxation by the authority under the tax identification number ...
(where applicable).
...
Date and place
@ internet - DGFiP
...........................................................................................................................................................................
Address
...........................................................................................................................................................................
...........................................................................................................................................................................
SIREN number
...........................................................................................................................................................................
...
Date and place
Seal
...........................................................................................................................................................................
Address
...........................................................................................................................................................................
...........................................................................................................................................................................
The abovenamed institution hereby certifies that, to the best of its knowledge, the applicant is a resident of the United States and
that the information provided on this form is correct.
...
Date and place
Seal
: .............. %
@ internet - DGFiP
5000-EN
For use by the
French tax
authority
ATTESTATION DE RESIDENCE
12816*01
Procdure normale
Dividendes
Procdure simplifie
Joindre un formulaire
annexe n 5001
File this certificate of
residence only
Intrts
Redevances
Joindre un formulaire
annexe n 5002
Joindre un formulaire
annexe n 5003
....................................................................................................................................................
....................................................................................................................................................
Profession
....................................................................................................................................................
....................................................................................................................................................
ou du sige social
....................................................................................................................................................
............................................................................................................................................
Le soussign certifie :
- tre le bnficiaire effectif des revenus pour lesquels le bnfice de la convention est demand ;
- avoir, au sens de la convention fiscale susvise, la qualit de rsident de (ou sagissant dun fonds de pension
ou dun
fonds ou d une socit dinvestissement tre tabli ) .....
;
- ne pas possder en France dtablissement ou de base fixe auxquels se rattachent les revenus ;
-
que ces revenus ont t ou seront dclars ladministration des impts de lEtat de rsidence.
...
Date et lieu
certifie qu sa connaissance :
- au sens de la convention fiscale susvise le bnficiaire a bien la qualit de rsident de (ou sagissant dun fonds de
pension ou dun fonds ou dune socit dinvestissement tre tabli ) .......
;
- le bnficiaire des revenus relve de son ressort sous le numro fiscal ......
(si un tel numro existe).
...
Date et lieu
Signature et tampon
@ internet - DGFiP
...........................................................................................................................................................................
...........................................................................................................................................................................
Numro SIREN
...........................................................................................................................................................................
Cachet
...........................................................................................................................................................................
...........................................................................................................................................................................
Ltablissement dsign ci-avant certifie qu sa connaissance le dclarant est un rsident des Etats-Unis et que les mentions
portes sur cette dclaration sont exactes.
...
Date et lieu
Cachet
: ...................... %